1. IMPACTED TEETH

2. Contents Glossary of Terms Theories of Impaction Causes Frequency
Classification
Rationale for Removal
Clinical & Radiological Assessment
Surgical Anatomy
Removal
Postoperative Care & Complications

3. Glossary of terms: Impacted teeth:
A tooth that has failed to erupt into normal functional position beyond the time usually expected for such appearance is impacted. Eruption is prevented by adjacent hard or soft tissue including overlying teeth, bone, or dense soft tissue.

4. Partial impaction:
A tooth that is incompletely erupted is a partial impaction may be seen clinically but is frequently malposed and always covered to some extent with soft tissue or bone.

5. Unerupted teeth:
A tooth that has not established normal full communication with the external environment of the oral cavity and remains contained within the hard or soft tissues of the jaw is referred to as Unerupted teeth.

6. Theories of Impaction By Durbeck
1) Orthodontic theory : Jaws develop in downward and forward direction. Growth of the jaw and movement of teeth occurs in forward direction any thing that interfere with such moment will cause an impaction (small jaw-decreased space).
A dense bone decreases the movement of the teeth in forward direction.
Causes for increased density of bone
a) Acute infection, b) Local inflammation of PDL c) Malocclusion, d) trauma, e) Early loss of primary teeth – arrested growth of the jaw.

7. 2) Phylogenic theory: Nature tries to eliminate the disused organs i.e., used makes the organ develop better, disuse causes slow regression of organ.
[More-functional masticatory force – better the development of the jaw]
Due to changing nutritional habits of our civilization have practically eliminated needs for large powerful jaws, thus, over centuries the mandible and maxilla decreased in size leaving insufficient room for third molars.

8. 3) Mendelian theory: Heredity is most common cause
3) Mendelian theory: Heredity is most common cause. The hereditary transmission of small jaws and large teeth from parents to siblings. This may be important etiological factor in the occurrence of impaction.
4) Pathological theory: Chronic infections affecting an individual may bring the condensation of osseous tissue further preventing the growth and development of the jaws.
5) Endocrinal theory: Increase or decrease in growth hormone secretion may affect the size of the jaws

9. Causes of Impaction Local causes:
Irregularity in the position and pressure of an adjacent tooth.
The density of overlying or surrounding bone.
Long continued chronic inflammation with the resultant increase in density of the overlying mucous membrane.
Lack of space due to under develop jaws.
Prolong retention of the primary teeth.
Premature loss of primary teeth.
Acquired diseases – such as Necrosis due to infection or abscess and inflammatory changes in the bone due to exanthematous diseases in child.

10. Systemic causes:
a) Prenatal causes – Hereditary
Misagenation
b) Post natal causes – All the conditions that may interfere with development of child.
- Ricketts - Anaemia
- Congenital syphilis - Tuberculosis
- Endocrinal disfunction
c) Rare conditions
- Cleidocranial dysostosis - Oxycephaly
- Progeria - Achondroplasia
- Cleft palate

11. Frequency of impaction in following order
Mandibular third molars
Maxillary third molars
Maxillary cuspids
Mandibular bicuspids
Mandibular cuspids
Maxillary bicuspids
Maxillary central incisors
Maxillary lateral incisors

12. Classification Mesioangular Horizontal
Angulation – George Winter (1926) described first classification system which is based on the angulation of the long axis of the impacted third molar with respect to the long axis of the second molar.
Mesioangular
Horizontal

13. Vertical
Distoangular

14. Buccal direction – Bucco version Lingual direction – Lingual version
In addition impacted teeth also can be angled in buccal and lingual direction.
Buccal direction
– Bucco version
Lingual direction
– Lingual version
Unusual position – torsiversion

15. Relationship to the anterior border of the ramus of the mandibular
Relationship to the anterior border of the ramus of the mandibular. Another method of classifying impacted third molar is based on the amount of impacted teeth that is covered with the bone of the mandibular ramus.
[by Pell & Gregory]
Class I :
Class II
Class III:

16. Relative depth of the third molar (Vertical plane) by Pell and Geogory : In this classification the degree is measured by the thickness of overlying bone, the degree of difficulty increases as the relative depth of third molar increases.
Position A:
Position B:
Position C:

17. Killey & Key’s classification
a) Based on angulation and position:
Same as George Winters.
b) Based on the state of eruption:
- Completely erupted
- Partially erupted
- Unerupted
c) Based on pattern of roots:
1) - Fused roots.
- Two roots.
- Two roots and multiple roots
2) Root pattern may be –
- Surgical favourable
- Surgical unfavourable

18. ADA classification:
- Soft tissue impaction
- Partial bony impaction
- Complete bony impaction
- Complete bony impaction with unusual complications

19. Rationale for removing impacted tooth. by Larry J. Peterson
Rationale for removing impacted tooth by Larry J. Peterson (JADA/Vol 123/1992 July)
Indications:
Preventing and treating pericoronitis.
For prevention of dental caries.
Orthodontic considerations.
To prevent pathosis.
Prevention of root resorption.
Impacted teeth and dental prosthesis.
Prevention of dental diseases.

20. Contraindications:
Extremes of age.
Medically compromised patient.
Probable excessive damage to the adjacent structures.
Prevention of fracture of jaws.

21. Clinical Examination History: Most patients are symptomatic.
If so then associated with-
(Pericoronitis / pain / swelling of the face / trismus / enlarged tender lymph nodes)
Intraoral examination-
Size of oral cavity.
Degree of mouth opening.
Size of tongue.
Palpation for external oblique & internal oblique ridge in relation with 3rd molar.

22. Widely used radiographs:
Periapical / OPG / Occlusion.
Radiological assessment:
Orientation of the tooth.
Position and depth of the tooth
Winter lines.

23. White line:
Red line:
As a general rule any tooth with redline 5mm or more is better remove under GA. If redline is 9mm or more in length the inferior surface of crown of impacted 3rd molar may be in level or even below the apex of 2nd molar
Amber line

24. Root pattern: Either Favourable
Unfavourable
Shape of the crown.
Texture of investing bone.
Position and root pattern of 2nd molar.
Relationship of 3rd molar to the inferior dental canal.

25. Interruption of white line of canal
Darkening of roots
Deflection of roots
Narrowing of roots
Dark & Bifid apex
Interruption of white line of canal
Diversion of canal
Narrowing of canal

26. DIFFICULTY INDEX Classification: Difficulty scores:
A) Spatial Relationship
Value
- Mesioangular 1
- Horizontal / transverse 2
- Vertical 3
- Distoangular 4
B) Depth
- Level A
- Level B
- Level C
C) Ramus relationship
- Class I
- Class II
- Class III
Difficulty scores:
Very difficult 7-10
Moderately 5-7
Minimally 3-4
Example: Mesioangular tooth 1 difficulty score is
Level B
Class III 3 Moderately difficult

27. WHARFE’ ASSESSMENT by McGregor (1985)
Category
Score
1. Winters classification
Horizontal
Distoangular
Mesioangular
Vertical 2 1
2. Height of mandible
1-30mm
31-34mm
35-39mm
3. Angulation of 3rd molar
1° - 50°
60° - 69°
70° -79°
80° - 89°
90°+ 3 4
4. Root shape
Complex
Favourable curvature
Unfavourable curvature
5. Follicles
Normal
Possibly enlarged
Enlarged
6. Path of exit
Space available
Distal cusp covered
Mesial cusp covered
Both cusp covered
Total 33

28. SURGICAL ANATOMY OF MANDIBULAR 3RD MOLAR
Temporalis muscle
Buccinator
Retro molar foramina

30. Surgical Removal Following Steps:
Anaesthesia
Incision and mucoperiosteal flap.
Removal of bone.
Tooth removal.
Wound debridement.
Arrest of haemorrhage.
Wound closure.
Post operative followup.

31. Armamentarium (i) Local anesthesia (vi) needle holder (xi) cross bars
(ii) 15 no. blade (vii) suture material (xii) retractors
(iii) Tweezers (viii) scissors
(iv) Curette (ix) chisels
(v) Elevators (x) mallet

32. Various incisions / Approaches
Standard Wards incision.
Modified Wards incision.
Envelope flap.
L-Shaped flap.
Comma incision.

33. Ward’s incision:
Modified Ward’s incision:

34. Envelop incision:
L-shaped flap:

35. REMOVAL OF OVERLYING BONE
I. Lingual split bone tech
(Sir William Kelsey Fry)
Advantages:
Quick & clean
Reduces the size of blood clot by means of saucerization of socket.
Disadvantages:
Only suitable for young adults therefore Elastic Bone.
More chances of getting post operating lingual nerve parasthesia.
Patients inconvenience.

37. II. Moor / Gillbes Collor tech:
Conventional tech of using bur.
Similar amount of bone is sacrificed same as split bone technique.
Can be used in old patient with.
Convenient for patient.
Is to create a gutter along buccal side & distal surface of tooth.
And a point of elevation is created with bur.

39. III. Lateral Trephination tech:
(Bowdler Henry)
Employed to remove any partially formed unerupted third molar that has not breached the hard & soft tissues overlying it.
Advantages:
Bone healing is excellent and here is no loss of alveolar bone around 2nd molar.

41. The tooth is sectioned in different ways.
Sectioning TECHNIQUE
The tooth is sectioned in different ways.

42. Horizontal impaction The tooth is sectioned in different ways.

43. Vertical impaction

44. Root abnormalities & different techniques of removal

45. Delivery of sectioned tooth from socket
By using appropriate elevators.
Straight elevator
Warwick James
Straight / Curved
Coupland’s
Cryer’s
Cross bar
Excessive force should be avoided to prevent injury
Soft tissues
Adjacent tooth / bone
inferior dental canal / lingual nerve

46. Debridement of wound & closure
Thorough debridement of the socket by
Periapical curette
Smoothening of sharp bony margins by
Bone file / round burs
Thorough irrigation of the socket
Betadine solution / Saline
Initial wound closure is achieved by
Just distal to 2nd molar
Posterior relieving incision
Inter dental area mesial to 2nd molar
3-4 are usually sufficient

47. Post-operative care Pressure pack Ice pack Avoid gargling / spitting
Soft diet
Warm water saline gargling after 12 hrs
Maintain oral hygiene
Proper medication

48. Complications Intra-operative Soft tissue injuries : facial vessels
Soft tissues
Lingual nerve
Inferior dental nerve
Bleeding – bone / soft tissue
Hard tissue injuries :
Osseous structures
Fracture of mandible
Injury to adjacent tooth

49. Post-operative Immediate Late Pain Infection Hemorrhage Dry socket
Swelling
Trismus
Parasthesia
Late
Infection
Dry socket
Osteomylelitis
Secondary Hemorrhage
Pain in TMJ

50. Recent advances Use of Erbium (Er):YAG laser [by M. Abu-Serriah / A
Recent advances Use of Erbium (Er):YAG laser [by M.Abu-Serriah / A.Ayoub : Bjoms 2004; 42: ]
Adv:
Less stressful
Less unpleasant
No vibrations & sound
Sharp clean cut through the bone & tooth
Can used anxious patients
Disadv:
Compensate for tactile feedback compare to bur.
Trismus is more
Time consuming
Costly

51. Thank you

52. MAXILLARY IMPACTED TEETH

53. Contents Maxillary impacted 3rd molar / impacted canine
Glossary of Terms
Classification
Rationale for Removal
Clinical & Radiological Assessment
Surgical Anatomy
Removal
Postoperative Care & Complications

54. Glossary of terms:
Impacted teeth:
A tooth that has failed to erupt into normal functional position beyond the time usually expected for such appearance is impacted. Eruption is prevented by adjacent hard or soft tissue including overlying teeth, bone, or dense soft tissue.

55. Partial impaction:
A tooth that is incompletely erupted is a partial impaction may be seen clinically but is frequently malposed and always covered to some extent with soft tissue or bone.

56. Unerupted teeth:
A tooth that has not established normal full communication with the external environment of the oral cavity and remains contained within the hard or soft tissues of the jaw is referred to as Unerupted teeth.

57. Impacted Maxillary 3rd Molars
Classified according to the:
Position of long axis.
Relative depth.
Sinus approximation.

58. POSITION OF LONG AXIS Can be Buccally tilted Palatally tilted
Mesioangular
Distoangular
Vertical
Horizontal
Can be
Buccally tilted
Palatally tilted

59. ACCORDING TO RELATIVE DEPTH
Class A
Class B
Class C
Sinus approximation
No sinus approximation

60. ACCORDING to Killey & Kay
Upper third molar may be:
Unerupted - Within the bone
- In soft tissues
Partially erupted
Fully erupted.
Any of these teeth may be
Mesioangular/Vertical
Laterally displaced & crown facing towards cheek.
Distally displaced.
Aberrant position.
Roots may be
Fused (conical).
Multiple – Favourable
Unfavourable

61. Indications for Removal
Pericoronitis.
Dental caries.
Pathosis.
Root resorption of 2nd molar.
Under dental prosthesis.
Causing chronic cheek biting.
Impinging on coronoid process.
Non-functional (when opposite tooth is removed).
Contraindications:
Extremes of age.
Deep seated tooth with no signs of pathosis.

62. SURGICAL ANATOMY

63. SURGICAL STEPS: Anaesthesia Incision and mucoperiosteal flap.
Removal of bone.
Tooth removal.
Wound debridement.
Arrest of haemorrhage.
Wound closure.
Post operative followup.

64. Factors complicating the removal of tooth
Maxillary sinus approximation.
Impacted upper 3rd molar just above the roots of 2nd molar.
Fusion of 3rd molar with roots of 2nd molar.
Hypercementosis.
Extreme bone density in elderly patients.
Difficult access.
Abnormal roots.

65. Conventional incision
Approaches
Envelope incision
Conventional incision

66. Technique of removing 3rd molar

67. Debridement of wound & closure
Thorough debridement of the socket by
Periapical curette
Smoothening of sharp bony margins by
Bone file
Thorough irrigation of the socket
Betadine solution / Saline
Initial wound closure is achieved by

68. Post-operative care Pressure pack Ice pack Avoid gargling / spitting
Soft diet
Warm water saline gargling after 12 hrs
Maintain oral hygiene
Proper medication

69. Complications Intra-operative Hard tissue injuries -
Fracture of tuberosity.
Damage to adjacent tooth
Soft tissue injuries -
Soft tissues
Injury to vessels / nerves
Bleeding – bone / soft tissue
Herneation of buccal fat
Dislodgement of tooth/ root into
Maxillary antrum
Soft tissue (infratemporal fossa)
Oroantral communication

70. Post-operative
Pain
Hemorrhage
Swelling
Infection
Dry socket
Osteomylelitis
Secondary Hemorrhage

71. Accidental displacement of impacted maxillary 3rd molar into infratemporal fossa (by M. Patel & Down) BDJ, 1994.
Frequently mentioned but rarely reported.

72. Action list for prevention of displacement

73. MANAGEMENT OF IMPACTED MAXILLARY CANINE TEETH
Classification
Class I – located in palate – horizontal / vertical
semi vertical
Class II – located in the labial or buccal surface of the
maxilla – horizontal/vertical/semivertical
Class III – Crown on palatal side and root on buccal side
or vice versa.
Class IV – located in alveolar process between incisor and
first premolar (usually vertical)
Class V – located in edentulous maxilla
[ or can be located in unusual position – nasoantral wall or infraorbital margin]

74. Anatomy

75. Dowels discussion of etiological factors of canine impaction
During the development of the crown of the permanent cuspid lies immediately lingual to the primary canine root. Any change in position of primary canine or premature loss of primary molar.
The hard palatal bone offers more resistance to the erupting canine.
The mucoperiosteal tissues covering anterior third of the palate are repeatedly subjected to stress and pressure during mastication becomes very dense thick and resistant.
Eruption of teeth is dependent to some extent of an associated increase in apical development. This aid to erupting canine is minimized because root normally / more fully formed at the time of eruption.

76. The tooth must travel at the greater distance from its point of development.
Delayed resorption of primary canine root.
Canines are the last permanent tooth to erupt in between the teeth already in occlusion.
Permanent canine is preceded by primary canine whose M-D is much lesser.

77. Clinical examination Intraoral
Bulge can be palpable on buccal / lingual side.
If impacted canine crown is in contact with apical 3rd of lateral incisor can cause deflection of tooth.

78. Radiographic Examination
IOPA radiograph
Occlusal radiograph

79. Techniques for removal of impacted canine
Semilunar incision
Angulated flap incision

80. Techniques for removal of impacted canine
Buccally placed
Bilaterally palatally placed

81. Technique for removal of mandibular impacted canine

82. Complications Damaged to adjacent tooth
Perforation of the palate (if placed buccally)
Perforation of nasal mucosa / floor
Perforation of anteral mucosa
Dislodgement of root into maxillary sinus
Haematoma

83. References Harry Archer – Oral & Maxillofacial Surg. Part 1
Geoffery Howe – Minor Oral Surg.
Killey & Kays - Outline of Oral Surg.
Daniel E. Wait – Textbook of Practical Oral & Maxillofacial Surg.
Peterson – Contemporary Oral & Maxillofacial Surg.
Dental Clinics of North America
Killey & Kay – The Impacted Wisdom tooth
Accidental displacement of impacted maxillary third molars (M.Patel,K.Down, Br.dent journal 1994 vol, 177/57-59)

84. Thank you